Mediastinoscopy is indicated for the staging of the mediastinal lymph nodes in cases of suspected or confirmed non–small cell lung cancer or to obtain diagnostic tissue in other cases of mediastinal lymphadenopathy. Level 2, 4, and 7 paratracheal lymph nodes are generally accessible to the mediastinoscope (Figure 1). Relative contraindications include prior thoracic radiation, previous mediastinoscopy, aortic arch aneurysm, tracheal resection, or functioning tracheostomy.
Computed tomography scanning of the chest as well as a whole-body positron emission tomography (PET) scan are helpful both in evaluating other areas of disease and in identifying areas within mediastinum that are of particular interest. Many of these patients have extensive comorbidities, and an electrocardiogram and laboratory evaluation including complete blood count, electrolytes, blood urea nitrogen, creatinine, glucose, and prothrombin and partial thromboplastin times are generally recommended.
General anesthesia with endotracheal intubation should be used. An arterial line and two large-bore intravenous lines should be placed, and the anesthesiologist should be prepared for an emergent sternotomy in case excessive bleeding is encountered.
The patient is placed supine on a flat table with a shoulder roll placed to extend the neck. The surgeon stands at the head of the patient, and the assistant stands to the surgeon’s right side. The surgical nurse stands on the right side toward the foot of the patient. The anesthesiologist stands to the patient’s left side (Figure 2).
The skin of the neck and entire chest should be prepared in the usual manner. Care should be taken that the operative field and drapes are placed such that emergent sternotomy is possible if bleeding is encountered.
A 2.5-cm transverse incision is made two fingerbreadths above the sternal notch. The platysma is divided transversely, and the strap muscles are divided vertically through the median raphe. Dissection is carried down to the trachea. Once the trachea is exposed, blunt dissection with a finger allows development of the pretracheal space (Figure 3). If dense adhesions are encountered, the procedure should be aborted. Throughout the procedure, it is important to stay immediately on the trachea to ensure that the surgeon is posterior to the great vessels crossing anteriorly.
At this point, the video-mediastinoscope is inserted (Figure 4). Attention is paid to staying immediately on the trachea as it is advanced inferiorly. The right level 2 nodes are accessible immediately after entry into the paratracheal ...